Springvale Private Nursing Home

RACS ID4300
340-344 Springvale Road
SPRINGVALE VIC 3171

Approved provider:Aged Care Services 25 (Springvale) Pty Ltd

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 29 April 2020.

We made our decision on 02 March 2017.

The audit was conducted on 31 January 2017 to 01 February 2017. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits.

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

Expected outcome / Quality Agency decision
1.1Continuousimprovement / Met
1.2Regulatorycompliance / Met
1.3Education and staffdevelopment / Met
1.4Comments andcomplaints / Met
1.5Planning andleadership / Met
1.6Human resourcemanagement / Met
1.7Inventory andequipment / Met
1.8Informationsystems / Met
1.9Externalservices / Met

Standard 2: Health and personal care

Principles:

Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.

Expected outcome / Quality Agency decision
2.1Continuousimprovement / Met
2.2Regulatorycompliance / Met
2.3Education and staffdevelopment / Met
2.4Clinicalcare / Met
2.5Specialised nursing careneeds / Met
2.6Other health and relatedservices / Met
2.7Medicationmanagement / Met
2.8Painmanagement / Met
2.9Palliativecare / Met
2.10Nutrition and hydration / Met
2.11Skin care / Met
2.12Continence management / Met
2.13Behavioural management / Met
2.14Mobility, dexterity and rehabilitation / Met
2.15Oral and dental care / Met
2.16Sensory loss / Met
2.17Sleep / Met

Standard 3: Care recipient lifestyle

Principle:

Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services and in the community.

Expected outcome / Quality Agency decision
3.1Continuousimprovement / Met
3.2Regulatorycompliance / Met
3.3Education and staffdevelopment / Met
3.4Emotionalsupport / Met
3.5Independence / Met
3.6Privacy anddignity / Met
3.7Leisure interests andactivities / Met
3.8Cultural and spirituallife / Met
3.9Choice anddecision-making / Met
3.10Care recipient security of tenure and responsibilities / Met

Standard 4: Physical

Principle:

Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.

Expected outcome / Quality Agency decision
4.1Continuousimprovement / Met
4.2Regulatorycompliance / Met
4.3Education and staffdevelopment / Met
4.4Livingenvironment / Met
4.5Occupational health andsafety / Met
4.6Fire, security and otheremergencies / Met
4.7Infectioncontrol / Met
4.8Catering, cleaning and laundryservices / Met

Home name: Springvale Private Nursing Home
RACS ID: 43001Dates of audit: 31 January 2017 to 01 February 2017

Audit Report

Springvale Private Nursing Home 4300

Approved provider: Aged Care Services 25 (Springvale) Pty Ltd

Introduction

This is the report of a re-accreditation audit from 31 January 2017 to 01 February 2017 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to care recipients in accordance with the Accreditation Standards.

To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards.

There are four Standards covering management systems, health and personal care, care recipient lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment.

Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards. The Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home.

Assessment team’s findings regarding performance against the Accreditation Standards

The information obtained through the audit of the home indicates the home meets:

  • 44 expected outcomes

Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 31 January 2017 to 01 February 2017.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of two registered aged care quality assessors.

The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014.

Assessment team

Team leader: / Ann De Pellegrin
Team member/s: / Gillian Walster

Approved provider details

Approved provider: / Aged Care Services 25 (Springvale) Pty Ltd

Details of home

Name of home: / Springvale Private Nursing Home
RACS ID: / 4300
Total number of allocated places: / 73
Number of care recipients during audit: / 64
Number of care recipients receiving high care during audit: / 63
Special needs catered for: / N/A
Street: / 340-344 Springvale Road
City: / SPRINGVALE
State: / VIC
Postcode: / 3171
Phone number: / 03 9546 6133
Facsimile: / 03 9546 6777
E-mail address: /

Audit trail

The assessment team spent two days on site and gathered information from the following:

Interviews

Category / Number
Facility manager / 1
Group/quality managers / 3
Group managers – domestic services/catering/maintenance / 3
Clinical care coordinators / 2
Clinical and care staff / 8
Medical practitioner/allied health professional / 2
Care recipients / 4
Representatives / 9
Training supervisor / 1
Lifestyle staff / 2
Hospitality staff / 6
Maintenance contractor / 1

Sampled documents

Category / Number
Care recipients’ files / 7
Medication charts / 11
Residential agreements / 7
Personnel files / 9
Service agreements / 5

Other documents reviewed

The team also reviewed:

  • Activity program and activity evaluations
  • Audit schedule and audits
  • Care recipients dietary information and summary records
  • Chemical register and material safety data sheets
  • Cleaning schedules
  • Clinical forms, charts and medication checklist
  • Comments, complaint and compliments records
  • Continuous improvement plan and related action forms
  • Education planner, staff education attendance and education evaluation records
  • Essential service and compliance reports
  • Food safety plan, associated records and compliance reports
  • Flowcharts – restraint, nutrition and hydration referrals, wound management, physical aggression
  • Handover sheets
  • Human resource documentation, job descriptions and duty lists
  • Incident reports and mandatory reporting register
  • Infection data and summary reports, monthly infection register/report
  • Information handbooks – care recipient, staff and contractors
  • Lifestyle participation records, privacy and dignity log, cultural and spiritual log
  • Maintenance – maintenance requests, preventative schedules and related records
  • Meeting minutes, memoranda and newsletter
  • Palliative care wishes form
  • Pest control documentation and service register
  • Privacy/confidentiality consent forms
  • Procedure manual, policies and procedures - selected
  • Regulatory compliance records, registers and related reports
  • ‘Resident of the day’ procedure
  • Restraint authorisation and information brochure
  • Rosters and staff allocation lists
  • Safe operating procedure manuals
  • Staff police certificate register and nurse registration status report
  • Self-assessment
  • Wound management register.

Observations

The team observed the following:

  • Activities and religious services in progress
  • Archive area, document destruction bin and confidential information secure
  • Backup kits - outbreak management, palliative care, power outrage
  • Equipment, supply and storage areas
  • Fire-fighting equipment, egress routes and evacuation maps
  • Interactions between staff and care recipients
  • Living environment – internal and external
  • Meal and refreshment service
  • Menu’s, information and brochure displays in multiple languages
  • Personal protective equipment
  • Pest control and waste disposal systems including sharps and yellow infectious bins
  • Safe storage of oxygen and chemicals
  • Short observation in the ‘Wilson/Ong’ dining room
  • Staff safe work practice and use of warning signage and work aids
  • Staff assisting care recipients with meals and refreshment
  • Storage and administration of medications
  • The ‘charter of care recipients’ rights and responsibilities’ displayed
  • The organisation ‘vision and mission’ statement displayed
  • Wound trolley and equipment
  • Visitor code of conduct displayed

Assessment information

This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards.

Standard 1 – Management systems, staffing and organisational development

Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

The organisation has established systems to actively pursue continuous improvement. A schedule of audits, surveys and questionnaires assist management to assess the home’s level of performance across the Accreditation Standards. Management use feedback mechanisms including the comments and complaints system, meeting discussions, incidents, observations and the changing needs of care recipients to identify opportunities for improvement. Management and staff respond to improvement opportunities at the time and record this information on action forms, the priority action register and/or the continuous improvement plan which show progress and outcomes. Management drive and evaluate the system in an ongoing manner with reporting of progress and results made available to related stakeholders and groups. Organisational management routinely monitor the home’s continuous improvement plan. Care recipients and staff are aware of continuous improvement activities.

Examples of recent improvements undertaken in relation to Standard 1 Management systems, staffing and organisational development include the following:

  • Management initiated and developed a student information pack which includes information about manual handling, infection control, safety and emergency procedures, a map of the home, public transport access, care recipients and other information. Management provide an introductory welcome talk to students highlighting person centred care, privacy and dignity and care recipient’s cultural and spiritual needs. Although recently implemented, training staff spoke of students’ positive feedback regarding their orientation, the information provided and being well prepared as to their practical experience and engagement with care recipients.
  • An organisational initiative resulted in the implementation of an electronic workforce management system. The project team trialled and implemented the system at various stages with education initially provided to the site manager and administration staff. Management provided information sessions and training to staff with resource manuals accessible for further assistance. Documentation shows various improvements related to the electronic system including timeliness of payroll and human resource processes.
1.2Regulatory compliance

This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”.

Team’s findings

The home meets this expected outcome

The organisation’s management has a system to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines in relation to the Accreditation Standards. The organisation receives updates and relevant information from government, industry, peak-body and professional associations. Management and committee groups review changes, develop or modify policies and procedures and arrange education to ensure alignment with changes. Management utilise orientation, information handbooks, education, meetings and other communication mechanisms to flag specific regulatory compliance changes. Management monitors compliance through quality activities, external audits and observation of staff practice. Staff are aware of their obligations in relation to regulatory compliance related to their roles and are informed when changes occur.

Examples of regulatory compliance obligations in relation to Standard 1 Management systems, staffing and organisational development include:

  • The home has a plan for continuous improvement.
  • Management demonstrated they notified care recipients and representatives by letter of the re-accreditation audit within the required notice time.
  • Stakeholders are provided with and have access to information regarding advocacy services and the internal and external complaint mechanisms.
  • The home has processes to ensure the currency of professional registrations.
  • There is a system to ensure compliance with police certificate requirements and statutory declarations as required for all relevant staff, volunteers and contractors.
  • Appropriate and secure information storage and destruction systems at the home.
1.3Education and staff development

This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.

Team’s findings

The home meets this expected outcome

Management and staff have appropriate skills and knowledge to perform their roles effectively. Organisational management develop a yearly education plan based on trend analysis, regulatory and organisational requirements, compulsory topics and competency evaluation. Additional education and training topics are scheduled as required in response to onsite incidents, quality activities, feedback and care recipients’ needs. A range of delivery methods include in-house and external sessions, competency training, ‘tool box’ sessions and self-directed learning. Management and staff attend a range of education topics and undertake competencies related to their role and across the Accreditation Standards. The organisation encourages and supports professional development such as up-skilling opportunities and provides support and time off for further education and studies. Site management monitor and evaluate the effectiveness of the program through incidents, quality activities, feedback and observations of staff practise. Management and staff are satisfied with the education and training opportunities offered.

Education and training attended by staff and relevant to Standard 1 Management systems, staffing and organisational development includes:

  • bullying and harassment
  • continuous improvement
  • documents and legal responsibility
  • electronic payroll system
  • regulatory compliance.
1.4Comments and complaints

This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms".

Team’s findings

The home meets this expected outcome

Each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms. Information about the internal and external feedback mechanism is included in stakeholder information and orientation programs. Brochures on the external complaints and advocacy services are accessible and available in languages reflective of care recipients living at the home. Management utilise a range of established informal and formal communication processes to encourage all stakeholders to provide feedback. This includes documented feedback forms, management’s open door approach, comment and discussions raised at stakeholder meetings and through confidential or anonymous input. Staff and family members support care recipients who are less able to express their feedback independently. Monitoring of actions to address identified issues occurs through quality activities and regular review of the comments, complaints and suggestions recorded. Care recipients, representatives and other stakeholders are aware of feedback mechanisms and feel comfortable to provide feedback.

1.5Planning and leadership

This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service".

Team’s findings

The home meets this expected outcome

The organisation has documented their vision and mission statement which includes their commitment to quality through their core values and service principles. Management displays this statement prominently in the home and repeats them in a range of internal documents.

1.6Human resource management

This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives".

Team’s findings

The home meets this expected outcome

The organisation has systems to ensure they recruit appropriately skilled and qualified staff to deliver quality care and services. There are recruitment, selection and orientation processes with new staff attending an induction program and being provided with ‘buddy’ shifts as required. Position descriptions and duty lists are current and define individual responsibilities. Management monitor and adjust staffing allocations. Rosters show adequate staffing levels and skill mix maintained at all times with a registered nurse on duty on all shifts. Casual and permanent staff cover planned and unplanned leave with the occasional use of agency staff. The organisation supports practical placement of the graduate nurse program at the home as an avenue for new staff. Management observations and quality activities ensure staff practice and knowledge is maintained and enhanced. Staff are satisfied with current staffing levels, human resource management and felt well supported by management. Care recipients and representatives are satisfied with staff skills, knowledge and attitudes and with staffing levels within care and support services.

1.7Inventory and equipment

This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available".

Team’s findings

The home meets this expected outcome

There are sufficient supplies of appropriate goods and equipment to provide quality service delivery. Key staff order clinical and non-clinical supplies through preferred suppliers and use effective stock management processes. All equipment and supplies are stored safely in secure areas and there are cleaning programs and maintenance schedules to ensure equipment remains in good repair. Care recipients, representatives and staff said they are satisfied with the quantity and quality of supplies and equipment available.